This website is a private website and is not associated, endorsed or authorized by the Department of Health and Human Services, the Center for Medicare and Medicaid Services or any other public or government organization or agency.

National
2017 Laboratory Fee Schedule

Effective April 1, 2013 and while sequestration is in effect, all CMS payments for services will be reduced by 2%. The fees below do not reflect this reduction.
Click here for more information.

When and how should I use an Advance
Beneficiary Notice (ABN) when running iSTAT tests?

When a Medicare
carrier is likely to deny payment because of medical necessity policy (for
example, when the diagnosis is not covered by national or local policy, a
frequency limit applies) the patient must be informed and consent to pay for
the service before it is performed, or they have no obligation to pay for the
test.

An Advance Beneficiary
Notice or ABN is used to document that the patient is aware that Medicare may
not pay for a test and has agreed to pay the provider in the event payment is
denied.Each ABN must be specific
to the service provided and the reason that Medicare may not pay for the
service.Blanket waivers for all
Medicare patients are not allowed.

An ABN must:

(1)be in
writing;
(2)
be obtained
prior to the beneficiary receiving the service;
(3)clearly
identify the particular service;
(4) state
that the provider believes Medicare is likely to deny payment for the specific
service;
(5) give
the reason(s) that the provider believes that Medicare is likely to deny
payment for the specific service; and
(6)
include the
beneficiary's signature and date.

Routine notices to
beneficiaries that do nothing more than state that Medicare denial of payment
is possible, or that the provider does not know whether Medicare will pay for a
service, will not be considered acceptable evidence of advance notice.Unacceptable practices include:

(1) giving
notice for all claims or services;

(2) failing to list the specific reason or rationale for likely denial;

(3) failing to state the particular test or service that Medicare is likely
to deny.

However, providers may
routinely provide ABNs is when the frequency of the test is restricted by
either a national coverage decision or a local medical review policy. In
this situation, a provider may provider an ABN almost every time the test is
performed because the provider has no idea how often the procedure has been
performed for the beneficiary in the past.

The CPT code
modifier, -GA (Waiver of Liability Statement on File), must be used to indicate that the provider has notified the
Medicare patient that the test performed may not be reimbursed by Medicare and
may be billed to the patient.

A standard CMS ABN
form must be used.CMS form No. CMS-R-131-L is specific
for laboratory use. CMS form No. CMS-R-131-G is for general use. These forms
are available on the CMS website athttp://www.cms.hhs.gov/medicare/bni.
The forms may be printed on the back of
laboratory requisitions, but must be single sided and may not be otherwise
modified except for the customizable boxes.

Completing an effective ABN:

Both ABNs
have customizable boxes that may be preprinted with check-off items. The
laboratory version contains three boxes:

The
first box is used to select
or list a specific test that is not covered because of local or national
coverage policy.

The
second box is used to select
or list a test that may be denied based on frequency limits.

The
third box is used to identify
research only or experimental tests that probably will not be
covered. A list of tests can be preprinted in each box and selected
as appropriate.

The
Estimated Cost item is
optional, lack of an entry or a value different from the actual cost billed to
the patient does not invalidate the ABN.

At
least two copies of the ABN are required; the provider retains the
original and gives a copy to the patient.

A
signature is not required so long as proof exists that the beneficiary was
notified that Medicare might not pay for a service or otherwise knew that
payment might be denied.

If
a beneficiary refuses to sign an ABN, but demands that the service be
provided, a witness can make a note to this effect and sign the ABN. The
beneficiary will then be responsible for the service if it is subsequently
denied.

A
patient must be notified far enough in advance to make a rational decision,
without undue pressure, as to whether they want a test or service and
are willing to pay for it. Patients should be given an ABN before they are
prepped for a procedure or otherwise put in a position where they feel they
cannot reasonably refuse treatment. ABNs should never be given to trauma
patients or in any EMTALA situation. ABNs given to patients under great
duress are not valid.

When Medicare
denies a service for which an ABN is on file, Medicare does not limit the
amount the provider can collect from the patient. However, billing a very
low amount (for example, significantly below what Medicare would
pay) might be considered an inducement and implicate violation of the
anti-kickback law.